Healthcare Provider Details

I. General information

NPI: 1073439741
Provider Name (Legal Business Name): DESIREE DIXON-CLARK MS, LBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 SLOCUM ST
FORTY FORT PA
18704-2936
US

IV. Provider business mailing address

166 SLOCUM ST
FORTY FORT PA
18704-2936
US

V. Phone/Fax

Practice location:
  • Phone: 570-846-0455
  • Fax:
Mailing address:
  • Phone: 570-846-0455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH008399
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: